Registered Nurses in Residential Aged Care

Transcription

1 The Professional Development Needs of Registered Nurses in Residential Aged Care Sharyn Hunter, RN, PhD, School of Nursing and Midwifery, University of Newcastle and Consultant, Anglican Care, New South Wales Margaret McMillan, RN, PhD, Faculty of Health, University of Newcastle, New South Wales Jane Conway, RN, DEd, Organisational Education Learning and Development, Northern Sydney Central Coast Health Service and School of Nursing and Midwifery, University of Newcastle, New South Wales This paper reports on research which used a multiple-case study approach to investigate the responses of aged care nurses to changes in Australian health care policy following the introduction of the Aged Care Act Significant fiscal, social and environmental issues for Residential Aged Care (RAC) are the: need to respond to policy changes emphasizing efficiency in RAC facilities, nature of the needs of residents with increasing acuity, impact of decreasing numbers of Registered Nurses (RNs) working in the RAC environment, changing composition of the care team and RAC RN functions. The study explored the phenomenon of the contemporary practice of (RNs) within six RAC settings, focusing on changes in the practice of RNs. As a result of the research a number of issues pertinent to staff and role development of RNs were identified. Key Words: residential aged care, practice development, change management, registered nurse roles Correspondence to: Professor Margaret McMillan Margaret.McMillan@newcastle.edu.au Introduction Aged Care in Australia is often regarded as the poor relation in health service provision. In contrast to the more high tech trademarks of health care work so often depicted through the media, aged care services are largely hidden from both the public and the professional view. Until 1997, nursing in RAC was conducted in a manner where specialist aged care knowledge and skills were not widely requested or required (Nay, 1993; Pesiah, 1991). This pattern prevailed despite the recognition and prioritisation of aged care nursing as an area for development in the latter part of the 1980s (Alexander, Jones & Magennis, 1992). Despite sustained efforts to develop nursing in Residential Aged Care (RAC) through education and research, widespread development of aged care nursing was not readily apparent. It took the introduction of seemingly extraordinary governmental regulations into the RAC industry, through the introduction of the Aged Care Act 1997, for there to be significant change in the operations of RAC facilities across Australia. Many facets of care delivery were modified to comply with the need to meet a set of standards and benchmarks in order to maintain funding. These modifications to care delivery impacted on the roles and functions of all staff providing client care. The research from which this paper is drawn emerged from an examination of the contemporary roles and functions of nurses in RAC following the implementation of the changes made in response to the Act. A number of theoretical frameworks for the research were drawn from sociological, psychological and organizational theories, with an emphasis on the concept of foresighting, the assessment of future conditions based on current conditions and trends (Skumanich & Silbernagel, 1997, p.1). A number of other studies directed the development of the questionnaires and surveys (Hicks & Hennessy, 1998; McCormack & Ford, 1999a, 1999b; Miller, 1995) as well as a Training Needs Analysis tool developed by Pedder (1998). Design A case study approach was used to meet the research objectives which were to: 6 Collegian Vol 14 No

2 The Professional Development Needs of Registered Nurses in Residential Aged Care explore the processes of change and the responses reflected in the practices of RNs in RAC facilities since the introduction of the Aged Care Act 1997, identify the scope of practice of RNs in RAC facilities using the Competency Standards for the Advanced Gerontological Nurse (Geriaction, 2000), identify the learning needs of RNs in RAC facilities, determine a model of optimal development for RNs in RAC facilities (this will not be reported here). The consensus among many authors about case study research is that it is a research strategy or design which makes use of multiple methods of data collection, straddling and making use of methods from the qualitative and quantitative traditions as appropriate in relation to the questions being examined (Bryar, 1999 p. 62). Method A purposive sample of six RACs selected against the criteria that research sites: had 3 years accreditation through the Aged Care Standards Accreditation Agency (as outlined in the Aged Care Act 1997 and managed by the Commonwealth Department of Health and Family services [CDHFS] (1997), were located within one geographic region (NSW), had more than 50 beds in order to ensure an adequate sample of RNs, had different owners (5 not for profit and 1 private) and were located in urban, rural and regional areas. A number of data types and collection techniques were used across all six RAC facilities. These were: Questionnaires for RNs and NMs developed for the purposes of this research Semi-structured interviews with RNs and NMs Collection of data from secondary data sources (eg information about RNs practice from job specifications). The pilot study participants (n=19) were drawn from RNs who worked in aged care and were enrolled in a graduate coursework program. Their completion of the survey and the interview process provided feedback on the tools. Feedback suggested that the tools demonstrated face and construct validity and that the study aims were meaningful and feasible. A correlation coefficient (Rho=0.926) demonstrated the stability of the survey. Both the pilot and main study activities were approved by both university and care facility s Ethics Committees. Within each research site, data for the main study were collected from two groups, RNs and Nurse Managers (NMs). As persons with learning needs may not always recognize their knowledge deficits (Smith, Smith & Ross, 1982), all RNs and NMs in each case were invited to participate in the research study. All RNS and NMs from all sites were invited to respond to the same questionnaire in order to compare perceptions of the RN role and learning needs associated with that from RN and MN perspectives. A total of 66 responses were received to the questionnaire distributed across all cases. Two of these were excluded due to incomplete responses. The remaining 64 included 48 RN and 16 NM responses. The questionnaire was designed to measure 2 different constructs, (a) the scope of RN practice and (b) learning needs. The first two sections of the questionnaire used a Likert Scale format to gain information about the frequency of performance of specified activity, while the third and fourth collected respondents demographic profiles and contained 2 opened ended questions - one about knowledge required and one about any other issues. The content of the questionnaire was the same for both groups. Semi-structured interviews further explored the perceptions of the 2 groups of questionnaire respondents about RN s practice in the context of aged care. Similar questions in the schedules (one for RNs and another for NMs focused on RNs practice) were prepared in order to explore what RNs do, how they practise and perceptions of how and to what extent change has occurred in the RN role. Construct, face and content validity tested through the use of expert advisors was enhanced through the use of the two groups of respondents. Data analysis The data sets were analyzed on both a case-by-case and casecomparative basis. Finally, overall analysis occurred when data from the different sources were pooled and data source and method triangulation (Denzin, 1978) were performed to achieve insight about answers to the following key questions: What is current practice for RNs in RAC? and How has change been implemented in RAC settings? Qualitative data were analyzed using content analysis as described by Morse and Field (1995). Several broad themes were initially identified and coded. Emergent categories, themes and sub-categories were crosschecked by a number of experts in data analysis. An assumption of the study was that frequency of performance of an activity reflected nursing practice. Quantitative questionnaire data were analyzed using descriptive and inferential statistics. A demographic profile of nurses was created using descriptive statistics. Chronbach s alpha test determined the reliability of the questionnaire. Inferential statistics and non parametric tests were used, as data sets were nominal and obtained from a small sample which did not have a normal distribution. Results The secondary data demonstrated various differences between the case profiles for residents, organization of staffing and the facility expectations of RNs practice. However there was considerable agreement within the other data sets (RN and NM) about the perceptions of RNs practice in all RAC facilities. The results of the study illuminated the similarities and differences in RN and NM perceptions of RN scope of practice and activity, and their learning or professional development needs. Collegian Vol 14 No

3 RN Responses to the Questionnaire Forty eight RNs (56%) completed the 28 item questionnaire about RN practice in RAC. Analysis of the responses in regard to scope of practice revealed that 20 items had frequencies indicative of daily practice in greater than 70% of instances and means above 4.0 on a scale of 1-5. This pattern was consistent across cases. These provide insight into current RN practice and included: Understanding the effects of ageing on residents physical body and behaviour, Managing the activities of clinical nursing staff and acting as a role model to less experienced nursing team members, Making clinical decisions based on prior experience yet knowing the limitations of their own practice, Understanding how to intervene when care is compromised by unsafe or illegal practice, Participating in ongoing education and quality improvement processes, Establishing a relationship with residents relatives or significant others and providing assistance for them and/or their relatives to make informed decisions, Performing clinical and social assessments and making changes to care, including referrals, after interpreting results from investigations and/or assessments, Collaborating with other health professionals or agencies to achieve care outcomes and incorporating other health professionals assessment data into care delivery, Facilitating the learning needs of other clinical nursing staff. Very few statistically significant differences in clinical practice were demonstrated for RNs in this study across elements of RAC location, ownership, or RNs qualifications and experience. However 8 practice items were statistically different across all cases. Response patterns for three items showing high frequencies indicate that they were perceived to be part of everyday practice: Organizing their own workload, Devising an individualized plan of care, and Establishing a relationship with residents. The remaining 5 of the 8 practice items had low frequencies and means, indicating evidence of infrequent practice: Developing policies in response to changes in legislation or clinical practice, Introducing appropriate research findings into practice, Giving advice to residents and /or their relatives regarding their legal rights, Identifying situations where ethical conflicts can occur, Appraising other clinical nursing staffs performance. Analysis of RN data in order to determine needs for learning indicated most RN respondents reported that they had minimal learning needs in relation to the practice related items tested. Perhaps not surprisingly, there appeared to be inverse correlation between the reported frequency of performance of a given practice item and an associated learning need. However, four learning needs were identified by RN respondents as a priority across all sites. These were: Develop policies in response to changes in legislation or clinical practice, Give advice for them and/or their relatives regarding legal rights, Introduce appropriate research findings into practice, and Access other aged care services. NM Responses to the Questionnaire Aggregate analysis of the 16 (75%) responses from all sites was conducted rather than a case by case analysis because of the small numbers of respondents per case. The NMs identified seven practice items which they perceived were not performed regularly by RNs and about which they felt RNS had learning needs. These were: Deciding the best use of available resources, Facilitating the learning needs of clinical nursing staff, Identifying situations where ethical conflicts can occur, Giving advice to them and/or their relatives regarding their legal rights, Appraising other clinical nursing staffs performance, Developing policies in response to changes in legislation or clinical practice, and Introducing appropriate research findings into practice. In addition to this, NM questionnaire respondents felt that RNs should also be supported to participate effectively in quality improvement. Inferential statistics (Kruskal-Wallis test) compared the responses for each practice item and learning item for the two different populations of the RNs and NMs. The RNs and the NMs agreed on the nature and extent of RNs knowledge with respect to 75 per cent of practice items. Table 1 depicts the statistically significant (p< 0.05) difference in perceptions of practice items understood derived from analysis of responses from NM and RNs. The greater the understanding score, the less the perceived learning need. Qualitative data derived from the open ended questionnaire and semi structured interviews confirmed quantitative findings. They also provided insight into the ways in which RN practice is changing in RAC and the process by which this change is occurring. The data confirmed that RNs have two major roles, one is to manage the care of the residents and aspects of the facility and the other is to have a broader range of skills and clinical expertise pertaining to the care of the aged. In response to the questions in interviews all respondents indicated that practice is busier, involves caring for residents with increased acuity, involves the use of a broader range of clinical skills, is more professional, is less hands on, and requires oversight of aspects of the care planning processes and greater involvement with relatives or significant others. Results from the 50% of survey respondents who agreed to be interviewed (RNs n = 21 and NMs n =11) also revealed ways in which change in practice has occurred as a direct result of the Act. Analysis of qualitative data sets pertaining to the question 8 Collegian Vol 14 No

4 The Professional Development Needs of Registered Nurses in Residential Aged Care Table 1: The frequencies of agree and strongly agree recorded for items of practice that produced significant p values when comparing RNs and NMs responses to understanding with respect to practice Understanding with respect to Practice RNs - % NMs - % How to introduce appropriate research findings into practice How to appraise other clinical nursing staff s performance How to decide the best use available resources How to participate in quality improvement Identify effects of ageing on the physical body/behaviour How to access other aged care services How has change been implemented in RAC settings? indicated perceptions that past practices of the RNs in RAC were rigid, inflexible, routinized and strongly influenced by the medical paradigm. The NMs authority maintained a situation in which RNs simply did as they were told. The present practice of RNs encompassed a willingness to be released from the oppressed style of practice and were developing commitment to and processes for, breaking the routines of old by:..//.. continually having to assert ourselves because the old way of practice was the rns on the floor tended to be almost like..//.. you just did as you were told (Reg2RN2) and people [RNs] are getting more motivated and more interested and wanting to achieve the goals that will bring our standard of care up. (R2RN2) The following excerpts are evidence that this was occurring within a consultative approach that has been embraced increasingly since 1997 by NMs and that this has provided greater confidence and nurturance for RNs: A (C)onsultative process which helped them and support..//..which assists them to adjust. (NM)..//.. The managers, knowing what they re on about..//.. We ve actually imparted all this information we had in education and we ve passed it on. We ve been progressive, we ve grabbed it and run with it..//.. (RN) The overall perception of the change process as reported by the NMs and the RNs was that there had been gradual adjustment to changes in policy: it s been a slow progression. We re finding that we ve got to be more educated, we can t just go onto that floor and just know these things..//..(rn)..//..it just sort of seeped in and we know how to do a lot of things but we don t necessarily know we know how to do it until we think about it. (RN) People [RNs] are getting more motivated and more interested and wanting to achieve the goals that will bring our standard of care up. (NM) and a realization that there is a need for RNs to be more overt in their decision-making, be more autonomous in their practice, use reflection on practice and embrace reform: Change is good, [and the need to] prioritize things we re going to achieve, goals long term //.. We re changing old habits [because] they re not constructive ideas. A lot of things have been put into place because they were convenient, now we re starting to look at issues. (RN) The overall impression of the practice changes resulting from the Act among both the RNs and NMs was that they have been positive for the care of the resident but that that their work life had changed significantly:..//.. keeping up with the change, keeping up with the government requirements, always the accreditation, making sure we ve got the systems in place and that they re working and getting the feedback when they re not. you know it is all those and things and to me the ultimate challenge is delivering it in a way that meets all these other requirements as well, but to me that s that top priority to care for the residents and doing it well. The interview data revealed that the NMs were the major driving force for the current developments of the practice of RNs in RAC facilities. The respondents acknowledged that the Australian Government provided the direction for change through the Act then the aged care organizations provided the broad interpretations of the changes. The NMs translated these changes into the reality of practice at each facility. The changes that were introduced by the Act significantly influenced the NMs management strategies. The demand for documentation of care forced the managers to change their management style from authoritarian to a more consultative approach to get the team to analyze and report on their practices. As the work involved in meeting the new standards was substantial, the NMs had to delegate managerial activities and accountability of care to the RNs. The NMs identified that the RN once was not involved in management but now that has changed: (T)hey haven t had to have it [management skills] before now. (M2NM1) in the past the RN was really another worker, they did medicatios..//.. they were there, the boss, the matron and DON were there and they set the rules. You just went along you just did your work. (R2NM1) The RNs acknowledged that they have an expanded role in the management of the care and of the facility: I m a floor manager not an officer manager, RNs manage residential aged care facilities 24 hours a day, I m a lot more involved in the whole running of the facility and coordinating, a lot more managing that I ve never had before. (R2RN1) Discussion of findings This study provided further evidence that the knowledge and practice of RNs in RAC underpins quality service delivery. It also demonstrated that there is both a desire and an expectation that RNs practise at an advanced level, develop and use a range of sophisticated skills in critical thinking, problem solving and reflective practice to deliver the best possible care to residents and that RNs view themselves as autonomous, action orientated, reflective practitioners who are accountable for their actions. When the RN s role expands to its full potential the development a different care approach towards the resident will be necessary. When more than one person is responsible for the delivery of the care, roles and function have to be clarified and fully appreciated by those performing them. Each person involved in the different aspects of care delivering must also be competent in their knowledge and skills. Individual variability or large differences in performance do not encourage continuity or quality of care. The study participants could see that Federal government policy and consequent funding of Australian health services directly affects the nursing profession (Jones, 1998). In the Collegian Vol 14 No

5 Australian context, decisions made by the Federal and State governments continue to exert influence on the direction of healthcare service delivery and shape the nursing practice arena. Since the introduction of the Act, aged care organizations in Australia have focused on achieving: Accreditation and Certification of buildings to ensure the continuation of the facility, and Mastery of the Residential Classification Scale to ensure the continuation of adequate funding for appropriate delivery of care processes that match residents assessed needs. Changed RN practice has been a consequence of the introduction of uniform standards and funding systems and deregulation of staffing patterns in the RAC facilities. The findings of this study suggest that RNs in RAC are in the process of moving from a primary role of clinician delivering task focused care to residents, consistent with what McMillan, Conway, Little and Bujack (2001) have described as an amplified primary role which involves clinician, delegation and managerial activities. Other interview data revealed that the development process has been slow with revolutionized spurts usually related to the number of RNs receiving education and support on a particular area. Both the RNs and NMs recognise that the RNs are required to practise differently: they are more accountable, involved in decision making in relation to both the residents and the facility, and are responsible for a greater range of clinical and managerial activities. Education of the RN, support by the NMs and general practitioners and changing nursing structures have all assisted with the development of the RNs practice. The study provided evidence that what was initially a topdown approach to stimulate change in RNs practice has given way to a more inclusive and collaborative approach between NM and RN to implementing change in the scope of RN s practice in the RAC setting. The study has provided further evidence that NMs are critical in the determination of how far their facility aligns with new demands instigated by the policy and practice changes that resulted from the Aged Care Act The NMs achieved a change in the status quo by consulting with and supporting the RNs and driving the changes at a facility level. This study finding is not surprising as researchers (Pearson, Hocking, Mott & Riggs, 1992a, 1992b, 1993) had already identified the leadership role of the NMs in RAC facilities. They found that the Director of Nursing s (DON s) attitude, commitment and interpersonal skills facilitated the delivery of high quality of care and life experiences of the residents (Pearson et al., 1992a). In this study, there was evidence that in each case, NMs and the RNs have worked closely together to develop the changing patterns within the RN s practice. Boroughs (1999, p.49) suggests that there are five essential elements that nurse administrators needed to be involved in to lead clinical staff to achieve proficiency. These are education, cooperation, collaboration, consistency and conscientiousness. This research demonstrated that while education has been critical, cooperation and collaboration between the NMs and RNs has also occurred. Consistent persuasion from the NMs to bring about changes in practice has occurred; the NMs realized there was no going back to the previous systems of funding and they had to change to ensure survival of the facility. The NMs have been conscientious in their pursuit of complying with the new legislation and this has led to the development of the RN s practice. The focus of the RN functions has moved to a higher level of concentration on the more advanced expression of certain sub roles and functions. Consistent with changes in other areas of nursing practice as identified by Conway and McMillan (2000), the impact of the nursing shortage, coupled with a questioning of the role of the RN in RAC has necessitated that nurses be involved in skill mix review and patient care modeling initiatives. Despite a suggestion in both the present and other studies that RNs have been caused to have their communication and assessment functions accommodate aspects of collegiality and peer support and, to embrace the essential place of education in their practice and to develop their capacity to better manage processes of delegation and supervision, this study indicated that RNs continue to demarcate between clinical and managerial roles and value what they describe as direct care delivery over managerial activities. This needs to be addressed in order to facilitate a match between realistic care processes by appropriately qualified staff and quality outcomes. Integral to this is the provision of support for RNs to adopt roles and functions that are more consistent with care facilitator rather than direct care giver roles (Conway & McMillan, 2005) and strategies to meet the learning needs inherent in adoption of those roles. In addition the study indicated that not all authority essential to the RNs higher order activities has been delegated by the NMs. Integral to the continued development of RNs is the need for the NMs management practices to be more planned, systematic, proactive, integrated and for continuation of devolved managerial activities to RNs. Conclusion The care of the aged has been influenced by a range of social, economic, political and organizational determinants. Much of the focus of policy makers has drawn attention to the fiscal imperatives arising from the need to manage the demographics of ageing. There is a need for the provision of aged care to be conducted in a way that is socially responsible, economically viable and consistent with provision of a caring environment for the older member of society. It is envisaged that the professional development of RNs in RAC proposed as a result of this study supports the provision of quality care. Whilst there are some limitations around generalizability of case study data, the use of multiple sites enhanced the credibility of the findings. It is clear that the provision of quality care relies 10 Collegian Vol 14 No

6 The Professional Development Needs of Registered Nurses in Residential Aged Care on the team caring for residents to function in a coordinated fashion based on principles of best practice. Further formal site specific evaluative research is needed so that providers of care for the elderly can justify their own approaches to the management of the care of the elderly. The study has demonstrated the change in RN practice has occurred because of responses from the facility managers, NMs, and individual RNs reactions to critical stimuli such as the Aged Care Act (1997). Through clarification of the critical stimuli, the behaviours acted out as reaction to those stimuli and assurance of the RNs ongoing appropriate development, the continuation of the roles and functions of RNs in the dynamic context of the RAC industry framework is assured. References Alexander, L., Jones, D., & Magennis, M. (1992). The care team. In V. Minichello, D. Alexander, & D. Jones (Eds), Gerontology: A multi-disciplinary approach, (pp ). New York: Prentice Hall. Boroughs, D. (1999). Documentation in the long term care setting. The Journal of Nursing Administration, 29(12), Bryar, R. (1999). An examination of case study research. Nurse Researcher, 7(2), Commonwealth Department of Health & Family Services (CDHFS). (1997). Standards for Aged Care Facilities. Retrieved from sacfindx.htm Commonwealth of Australia (CA). (1997). Aged Care Act Canberra: Commonwealth of Australia. Conway, J., & McMillan, M. (2000). Maximising learning opportunities and preparing for professional practice. In J. Daly, S. Speedy, & D. Jackson (Eds.), Contexts of nursing: An introduction, (pp ). Sydney: MacLennan & Petty. Conway, J., & McMillan, M. (2005). Making the transition to professional nursing: Becoming a lifelong learner. In J. Daly, S. Speedy, D. Jackson,V. Lambert, & C. Lambert (Eds.), Professional nursing: Concepts issues and challenges, (pp ). Springer: New York. Denzin, N. (1978). The research act. New York: McGraw Hill. Geriaction. (2000). Competency standards for the advanced gerontological nurse. Australia. Hicks, C., & Hennessy, D. (1998). A triangulation approach to the identification of acute sector nurses training needs for formal nurse practitioner status. Journal of Advanced Nursing, 27(1), Jones, D. (1998). The impact of political policy on the nursing profession. Australian Nursing Journal, 5(10), 1. McCormack, B., & Ford, P. (1999a). Gerontological nursing research: Developing a user-focussed agenda. Elderly Care, 11(5), McCormack, B., & Ford, P. (1999b). The contribution of expert gerontological nursing. Nursing Standard, 13(25), McMillan, M., Conway, J., Little, P., & Bujack, E. (2001). Scope of nursing practice: Implications for nurse education in Australia. November 2001 report to DETYA. Miller, S. (1995). The clinical nurse specialist: A way forward. Journal of Advanced Nursing, 22, Morse, J., & Field, P. (1995). Qualitative research methods for health professionals (2nd ed.). California: Sage Publications. Nay, R. (1993). Benevolent oppression: Lived experiences of nursing home life. Sydney: School of Sociology, University of New South Wales. Pearson, A., Hocking, S., Mott, S., & Riggs, A. (1992a). Skills mix in Australian nursing homes. Journal of Advanced Nursing, 17, Pearson, A., Hocking, S., Mott, S., & Riggs, A. (1992b). Management and leadership in Australian nursing homes. Nursing Practice, 5(2), Pearson, A., Hocking, S., Mott, S., & Riggs, A. (1993). Staff in Australian nursing homes: Their qualification, experience and attitudes. Contemporary Nurse, 2(1), Pedder, L. (1998). Training Needs Analysis. Nursing Standard, 13(6), Pesiah, C. (1991). Caring for the institutionalised elderly: How easy is it? Australian Journal of Public Health, 15(1), Skumanich, M., & Silbernagel, M. (1997). Foresighting around the world: A review of seven best in-kind programs. Retrieved from services/e7s/foresite Smith, I., Smith, J., & Ross, G. (1982). Needs assessment: An overview for health educators. Mobius, 2(2), Collegian Vol 14 No